=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528398286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHISHOLM CHIROPRACTIC CENTER P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2009
-----------------------------------------------------
Last Update Date | 12/31/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 HILLSBOROUGH ST
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27603-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-829-5757
-----------------------------------------------------
Fax | 919-829-5808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 HILLSBOROUGH ST
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27603-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-829-5757
-----------------------------------------------------
Fax | 919-829-5808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. CHAD ERIC CHISHOLM
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 919-829-5757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 2063
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------